THE AUSTRALIAN AND NEW ZEALAND SOCIETY FOR VASCULAR SURGERY

Transcription

1 THE AUSTRALIAN AND NEW ZEALAND SOCIETY FOR VASCULAR SURGERY RESPONSE TO THE REVIEW OF THE MBS NOVEMBER 2015

2 PREAMBLE The ANZSVS is the peak representative organisation representing vascular surgeons in Australia and New Zealand. The organisation is responsible for the training of vascular surgeons in conjunction with the Royal Australian College of Surgeons (via the Board of Vascular Surgery). The ANZSVS has oversight of the Australian Vascular Audit, a web-based audit of surgical activity, a tool for continuing professional development required for membership of the Society. Through the Society s Annual Scientific Meetings (Spring Meeting and the RACS Annual Scientific Congress), the ANZSVS provides a forum for regular scientific exchange within Australasia and internationally. The Vascular Foundation- co-sponsored by the ANZSVS and the NZ Vascular Research Foundation provides funding for basic science and clinical research in vascular disease. Through its elected executive, the ANZSVS provides political representation for the membership of the Society, The rapid technological evolution of vascular surgical interventions in the last two decades has led to significant changes in the practice of vascular surgery. Many procedures that are evidence-based and frequently performed with established beneficial outcomes are either absent from the current MBS schedule or poorly described. This has led to confusion by surgeons, Medicare billing staff and private health funds and is the reason for the known variation in the use of item numbers in the current schedule. The need for review of the Medicare Benefits Schedule (MBS) is required. The ANZSVS supports the current review undertaken and believes that it has an important and appropriate role in providing expert advice on vascular surgery to the Review.. Representatives of the ANZSVS have attended stakeholder forums and engaged in the most recent round of consultations run by Professor Bruce Robinson and other members of the Taskforce. Following these discussions and internal conferences, the ANZSVS makes this submission to the Taskforce. It is the view of the ANZSVS that the issues that have been raised to date by the MBS review are myriad and complex going beyond a simplistic review of item numbers and levels of remuneration but also includes alternative administrative arrangements, consideration of alternative models of commonwealth funding for healthcare and reforms affecting arrangements between various components of the health system. The ANZSVS therefore believes that the time frame nominated for the completion of the review is inadequate both from the view of provision of appropriate time for deliberation and also from the view of internal consultation within the ANZSVS. Page 1 of 7

3 SUBMISSION Nonetheless the following represents the initial submission of the ANZSVS of issues relevant to vascular surgeons. A more detailed and comprehensive submission on the MBS schedule reflecting the view of the ANZSVS will be submitted following the release of the first draft of recommendations of the Taskforce, which we understand will be in December THE VALIDITY OF PRESUMPTIONS RAISED BY THE REVIEW a. appropriateness of care b. avoidable consultations c. Outcome based reimbursement 2. SPECIFIC CONCERNS OF THE ANZSVS a. bundling of services and rebate modifiers b. Appropriate role of surgical assistants 3. ITEM NUMBER REVIEW IN AREAS SPECIFIC TO VASCULAR SURGERY a. Reducing the complexity of the schedule b. Reform and retraining user and administrator c. After-care options d. A rational alternate system to assess new procedures 4. ANZSVS REPRESENTATION ON PROPOSED EXPERT CLINICAL REVIEW COMMITTEES OF THE MBS REVIEW a. Requirement for effective representation b. Inter-relationship with diagnostic radiology including diagnostic and procedural ultrasound Page 2 of 7

4 DETAILED DISCUSSION 1. THE VALIDITY OF PRESUMPTIONS RAISED BY THE REVIEW a. appropriateness of care b. avoidable consultations c. Outcome based reimbursement Vascular surgeons provide consultation and procedural care to patients with vascular disease where appropriate and when a beneficial outcome is likely for the patient. The disease process treated and the patient population treated are often frail, elderly and complex and outcomes are determined by many factors including many that are not easily predictable or evidence based. The MBS schedule is used by vascular surgeons to bill for the most appropriately described service provided consultation or procedure. The variability in interpretation of the current schedule arises because of the lack of clarity of the schedule and the myriad of possible item numbers that are available which could be used for said interventions. The variability in usage of the schedule is usually not an indication of any differences in the appropriateness of care provided and should not be presumed as such. Variations in clinical practice of vascular surgery may exist due to the complex nature of the risk-benefit assessment in high risk patients with multiple and complex co-morbidities. The small cohort of vascular surgeons, particularly in certain states may create an unusual pattern of use due to the practices of a particular surgeon. The concept of avoidable consultations is one that the ANZSVS counsels caution and careful definition by the Review. Many patients seek consultation with vascular surgeons via referrals from general practitioners and other specialists to exclude serious vascular disease. Until reviewed by the vascular specialist, potential limb or life threatening conditions cannot be excluded. Similarly, any system that creates a barrier to timely and appropriate review by vascular surgeons following vascular interventions has the potential to impact on patient care and lead to adverse outcomes. The ANZSVS counsels caution in any consideration to match reimbursement with outcomes. Many operations that are necessary for saving lives and salvaging limbs are performed in high risk patients. Key outcome measures exist to ensure that vascular surgical procedures, are performed with acceptable risks. The processes of regular and robust audits of practice and peer review within institutions exist to ensure outliers are identified and appropriate measures are taken to address these when they occur. The ANZSVS has gained international recognition in developing a peer reviewed audit of major vascular and endovascular surgery to facilitate the conduct of safe and high standard vascular and endovascular surgery throughout Australia (and New Zealand). The ANZSVS has developed a certificate system complemented by an internal and external validation process to ensure compliance and truth. This is known as the Australasian Vascular Audit A reimbursement model that is outcomes-based is likely to lead to risk-averse practice which is not compatible with appropriate modern day vascular surgical practice and is likely to lead to an undertreated patient population. Page 3 of 7

5 2. SPECIFIC CONCERNS OF THE ANZSVS a. bundling of services and rebate modifiers b. Appropriate role of surgical assistants Any bundling of services must be done with regard to the time, input of equipment and training required for the bundled services. The bundling of currently separate services must reflect these factors which may require adjustment of the fee. Care must be taken not encourage unnecessary or over-servicing as separate item numbers allows for choice to perform an extra service when appropriate, or not when it is not appropriate. Therefore bundling must be informed by published academic evidence, as well as by experienced clinicians who are responsible for providing care to patients, and understand the ecology of the area of practice. The level of assistance at operations varies enormously, but the provision of a fee for skilled assistance or even a second surgeon is essential for the safe conduct of complex major vascular (open and endovascular) operations. Whilst a flat rate, 20% type solution as currently applied may no longer be deemed appropriate, a system which more closely aligns with need/skills must ensure that an assistant can be readily found when required. Re-designing the system of payment of assistants must take into account the need for surgical assistance for large and complex surgery, but take into account the practical reality of reliable provision of service when required. Page 4 of 7

6 3. ITEM NUMBER REVIEW IN AREAS SPECIFIC TO VASCULAR SURGERY a. Reducing the complexity of the schedule b. Reform and retraining user and administrator c. After-care options d. A rational alternate system to assess new procedures Vascular Surgeons, like other users of the MBS Schedule procedure list, continue to be frustrated with the oft-times lack of clarity of the procedure descriptors. Whilst more complex descriptors may be required for new procedures to avoid the current misuse of older item numbers such as for those endoluminal procedures that have largely replaced their older open cousins, a simpler system guiding clinicians, and a better system to communicate those item numbers not to be claimed in concert with the dominant item number is needed. (Note the difference in descriptors, for example between and Avoiding inappropriate bundling of items in claims is poorly managed both by clinicians and the Medicare Branch and surely leads to undue criticism of both groups.) It is clear that reforms in the MBS will require training of both users and Medicare personnel charges with administration the schedule. The current system of having exclusions as separate lists within the schedule publication in the first 100 pages, then sometimes again appearing within individual descriptors creates unnecessary complexity and should be simplified. Examples of the above are the following common arrangement vascular surgeons currently have to deal with appears in paragraphs such as T.8.37 describing restrictions for Arterial and Venous Patches - (Items to and 34815). Similarly, for Item 34106, we find the descriptor thus: ARTERY OR VEIN (including brachial, radial, ulnar or tibial), ligation of, by elective operation, or exploration of, not being a service associated with any other vascular procedure except those services to which items 32508, 32511, or apply. Similar confusion surrounds item number An efficient computer-based relational database is urgently required for all clinicians to allow claims errors to be avoided, the search for appropriately related items to be simplified and clarity to be increased. After-care remains a real issue and must be standardized to reduce confusion. If after-care is not applied to all procedural item numbers, one could argue that, given that after-care is so poorly defined at present, it should be scrapped altogether. If done, it should lead to an associated reduction in payment for those procedures currently funded with after-care included. It must also result in the creation of formal, after-care item numbers linked to the level of complexity of the procedure employed and the patient s health. Further, to avoid misuse of this new group of items ranked in value according to the procedure s complexity (if not claimed by the operating surgeon), the item may only be claimed by the practitioner to whom the patient would be referred by the treating surgeon, similar to specialist referrals but with a duration limited in time for between two and eight weeks. If descriptors cannot solve the problems we face, alternative solutions need to be explored. The learned Colleges and Societies, with their specialized knowledge of members patterns of practice could be considered as groups able to establish a rapid-response mechanism for the Commonwealth Department of Health to gain an answer to the acceptability for the use of more than one item number for a complex procedure. As an alternative to MSAC, the establishment of a set of general descriptor items under each sub-set of procedures within the Vascular Procedures section of the MBS Schedule. The description of the procedure carried out and supplied to Medicare must be relatively clear, not brief, and put forward by the surgeon claiming the payment and what item number(s) he or she considers does not cover the procedure. Such a committee of the Department of Health would necessarily include nominees of the Society who could review the decision as to the appropriate reimbursement (based on particular related item Page 5 of 7

7 numbers) and assist in assessing the complexity of the described procedure. The decision must be based on the science currently available to support such a procedure currently not on the Schedule and the patient and Health Fund must not be disadvantaged. Such a process would lead to the creation of new item numbers, appropriately remunerated, when it becomes apparent to the committee that a significant number of such procedures are being claimed. It also gives the opportunity to reject the request for payment if the clinicians believe the claim is inappropriate, for they would be able to cite the item number that they believe is more acceptable. The knowledge acquired would also lead to regular and timely refinement of unsatisfactory descriptors and may even lead to the testing of decisions to delete item numbers for procedures considered to be without satisfactory clinical evidence. Page 6 of 7

8 4. ANZSVS REPRESENTATION ON PROPOSED EXPERT CLINICAL GROUP OF THE MBS REVIEW a. Requirement for effective representation b. Inter-relationship with diagnostic radiology including diagnostic and procedural ultrasound The Vascular Surgery Clinical Group will need a membership of senior practicing surgeons with skills and experience in both open and endovascular surgery including varicose vein disease, and these clinicians will need to have a practice involving interventional radiological skills to assess the value, appropriateness and inadequacies of the current MBS Schedule. Also needed is a vascular surgeon who also has advanced training and experience in diagnostic vascular ultrasound including duplex imaging of deep and superficial venous valvular disease not simply for point-of-care imaging. Their skills should include the running of vascular ultrasound laboratory. It is unlikely that such a range of skills would be present is less than three vascular surgeons. Vascular surgeons provide high quality non-invasive vascular diagnostic imaging which over the last years has been revolutionary in largely obviating the need for invasive angiography as a diagnostic tool with its consequent beneficial effects on cost reduction and patient safety. Vascular diagnostic imaging laboratories run by vascular surgeons are recognised as the gold standard in vascular imaging Vascular surgeons are active members of the government s ongoing diagnostic imaging committees (The MIC Accreditation Committee and the Diagnostic Imaging Advisory Committee). Vascular surgeons are also trained and skilled in the safe provision of angiography during endovascular therapeutic are skilled in the necessary reading of scans, particularly ct scans, independent of other specialists. This is necessary for the urgent management of life, limb and brain threatening situations Because of the close relationship in some of the work patterns of vascular surgeons and interventional radiologists, a vascular surgeon should also be a member of the Interventional Radiology Clinical Group. Discussions relating to diagnostic ultrasound item numbers and cardiology in other clinical committees will require assistance and consultation with vascular surgeons given significant overlap in the use of both procedural and diagnostic item numbers by these three groups. Vascular surgeons being involved on an ad-hoc basis initially in these groups may not be sufficient, and may lead to their involvement in such committees on a more permanent basis. Given the relationships amongst these groups we believe such cross committee discussions are essential to prevent misunderstandings and tensions well before each committee develops its draft position statement on the item numbers they use and the value of those items.. Page 7 of 7